Thank you for choosing Children's Medical Group of Greenwich Physicians as your (your child’s) health care provider. Please be assured that your and your child’s health care is of the utmost importance to us.
Thank you for taking the time to review our policies. Your clear understanding of our Financial Policy is important to our professional relationship with you. Please feel free to ask any questions or share any special concerns that you may have.
- Co-Payments/Coinsurance/Deductibles – Your specific insurance plan determines the amounts you may be required to pay. Our contract with your plan and applicable laws prohibit us from discounting or waiving copayments, deductibles, or coinsurance for visits and procedures. Copays are required at the time of every visit and Children's Medical Group of Greenwich accepts cash, check or credit card as payment.
Some insurance plans may require an additional copay for additional services done at your appointment. If this is required by your insurance, we will require the additional copayment at the time of service. If you have any questions regarding the additional copay requirement, we suggest you contact your insurance carrier to review your plan details. For your convenience, Children's Medical Group of Greenwich utilizes a credit card processing system which allows us to keep your credit card on file securely. Please note that no staff members at Children's Medical Group of Greenwich have access to your credit card number at any time. We will charge your card for amounts due, as indicated by your insurance carrier unless you advise us otherwise.
- No Show/Late Cancel Policy – A $40 surcharge will be applied to your balance if you (your dependent) do not arrive for an appointment and do not cancel prior to 24 hours before the scheduled visit.
- Insurance – We will require a copy of your (or your dependent’s) insurance card for our files. It is your responsibility to inform us of any change in your insurance coverage.
- Participating Plans – Children's Medical Group of Greenwich participates in most insurance plans. In order to properly bill your insurance company, we require all insurance information including primary and secondary insurance, as well as any change of insurance information. Failure to provide complete insurance information may result in patient responsibility for the entire bill. It is the insurance company that makes the final determination of your eligibility and benefits and you are responsible for any co-insurance, deductibles or non-covered services not paid by your insurance.
- Non-Participating Plans – If we are out of network for your insurance and your insurance will be paying you directly, we expect payment at the time of service unless other arrangements have been made prior to the visit.
- Referrals – If your insurance company requires a referral, it is your responsibility to obtain it prior to the visit and have it at the time of the visit. If you do not have the referral, you will be required to sign a financial waiver making you responsible for your bill if the referral is not obtained in time to have the visit covered by the insurance company.
- Self-Pay – Payment is expected at the time of visit unless other arrangements have been made with the office manager prior to the visit.
- Annual Visits – Before making annual physical appointments, it is your responsibility to check with your insurance company regarding whether the visit will be covered as a well visit. Not all plans cover annual physicals.
- Non-Covered Services – We pride ourselves on providing exceptional, state-of-the-art medical care, and extended services for our patients. We offer many health screenings that are recommended by the American Academy of Pediatrics and our providers. Some insurance companies choose not to pay for recognized service codes and apply these services to a patient’s deductible. Any non-covered service is your responsibility. This can include but is not limited to hearing screens, vision screens, lab work, and developmental screening; even when they occur at a well visit. If not covered, you will be responsible for those charges according to your benefits plan. Plans differ within each insurance company, so it is impossible for us to know what routine health screenings your plan will or will not cover.
- Financial Hardship – We realize some families from time to time experience financial difficulties and we want to always be here to care for your children. Please contact our office manager to discuss payment options.
- PATIENT FINANCIAL RESPONSIBILITY
– I acknowledge full responsibility for services rendered by Children's Medical Group of Greenwich. I understand that I am responsible for prompt payment of any portion of the charges not covered by insurance. I understand that co-pays are due at the time of check-in. Adolescents who come alone should be prepared to settle their visits at the time of service Children's Medical Group of Greenwich is not a party in divorce or separation decrees, or in child support arrangements. We bill one guarantor at one address. We do not handle billing or insurance coverage disputes between parents. In situations of divorce or separation of parents or guardians, the individual bringing in the child for services will be held financially responsible for any unpaid charges on the account. I authorize Children's Medical Group of Greenwich to release information to Medicare/other insurance carriers responsible for my or my dependent’s care. I request that payment of authorized Medicare/other insurance company benefits be made either to me or on my behalf to Children's Medical Group of Greenwich for any services rendered. I give consent to Children's Medical Group of Greenwich, its staff, physicians, and other practitioners to provide and perform such medical care, tests, procedures, and other services that are deemed necessary or beneficial by Children's Medical Group of Greenwich for my (child’s) health and well-being. There will be an additional charge submitted to your insurance company for patients seen on Saturdays, Sundays, federal holidays, and after normal business hours on weekdays. We are required by law to report all the charges for services provided. Some insurance companies cover the charge in full, and others assign all or part to patient responsibility. If you have any questions about your specific coverage, please ask your insurance company. As plans within the same company differ, it is impossible for us to know in advance if there will be any patient responsibility. For high insurance deductible plans, we may require a deposit towards your policy deductible requirements. You will receive a statement for any outstanding balances owed for services provided.
Please Print this PDF form – fill out the form at the bottom, sign and date the Financial Policy and bring with you at your next visit. Thank you!